What is the Insurance Process? Do I even Qualify?
Navigating through the insurance process, and getting the correct answers, can be daunting at best but here are some tips that will hopefully help you to get the right answers by asking the questions in the language the most insurance repersentatives can understand.
Insurance companies make their determination of who qualifies for bariatric surgery (if bariatric surgery is included in your contract) based on a patient's Body Mass Index, or BMI for short. BMI is a weight-to-height ratio, calculated by dividing one's weight in kilograms by the square of one's height in meters and used as an indicator of obesity and underweight. If you're a math wiz, you can try the calculation on your own. Otherwise, click on the link below and enter your height and weight and the BMI calculator will calculate our information for you.
Calculate your BMI
Most insurance companies will consider you to qualify for bariatric surgery with a BMI of 40 or greater or a BMI of 35 - 39.9 with at least one qualifying comorbid condition such as Type II Diabetes, Hypertension, Sleep Apnea or Heart Disease. That being said, not all insurance contracts include bariatric surgery as an option. The best way to determine if your insurance coverage does have bariatric coverage is to contact the 1-800 phone number on the back of your insurance card and ask the following questions to ensure that you not only understand if there is coverage, but what exact criteria you will need to meet and what financial responsibility you can expect to incur.
1. Does my coverage include bariatric surgery?
- Provide the customer service representative with the diagnosis for morbid obesity (ICD-10 Code E66.01) as well CPT code (below)
- The surgery codes are as follows. If you have not chosen a procedure, just choose any of the codes below:
Laparoscopic Roux en Y Gastric Bypass Surgery (CPT 43644)
Vertical Sleeve Gastrectomy Surgery (CPT 43775)
Adjustable Gastric Banding Surgery (CPT 43770)
- If your BMI is less than 40 (between 35 and 39.9), what comorbid conditions qualify under your coverage?
2. If your insurance contract does have coverage for bariatric surgery, ask the following:
- Is there any structured dietary requirements prior to surgery? If so, how long and do those visits need to be consecutive?
- If there is dietary requirements, are those dietary visits covered with the diagnosis of ICD 10 Code E66.01?
- Is there a weight history requirement (do I have to document a BMI for a certain period of time)
- All Centers of Excellence Programs will require a psychological evaluation. Ask if this will be covered.
- What is my deductible amount? Is this per calendar year or plan year? Is this an individual or family deductible?
- Once my deductible has been met, what percent of all eligible expenses are my responsibility up to my out of pocket maximum?
- What is my out of pocket maximum?
Insurance companies make their determination of who qualifies for bariatric surgery (if bariatric surgery is included in your contract) based on a patient's Body Mass Index, or BMI for short. BMI is a weight-to-height ratio, calculated by dividing one's weight in kilograms by the square of one's height in meters and used as an indicator of obesity and underweight. If you're a math wiz, you can try the calculation on your own. Otherwise, click on the link below and enter your height and weight and the BMI calculator will calculate our information for you.
Calculate your BMI
Most insurance companies will consider you to qualify for bariatric surgery with a BMI of 40 or greater or a BMI of 35 - 39.9 with at least one qualifying comorbid condition such as Type II Diabetes, Hypertension, Sleep Apnea or Heart Disease. That being said, not all insurance contracts include bariatric surgery as an option. The best way to determine if your insurance coverage does have bariatric coverage is to contact the 1-800 phone number on the back of your insurance card and ask the following questions to ensure that you not only understand if there is coverage, but what exact criteria you will need to meet and what financial responsibility you can expect to incur.
1. Does my coverage include bariatric surgery?
- Provide the customer service representative with the diagnosis for morbid obesity (ICD-10 Code E66.01) as well CPT code (below)
- The surgery codes are as follows. If you have not chosen a procedure, just choose any of the codes below:
Laparoscopic Roux en Y Gastric Bypass Surgery (CPT 43644)
Vertical Sleeve Gastrectomy Surgery (CPT 43775)
Adjustable Gastric Banding Surgery (CPT 43770)
- If your BMI is less than 40 (between 35 and 39.9), what comorbid conditions qualify under your coverage?
2. If your insurance contract does have coverage for bariatric surgery, ask the following:
- Is there any structured dietary requirements prior to surgery? If so, how long and do those visits need to be consecutive?
- If there is dietary requirements, are those dietary visits covered with the diagnosis of ICD 10 Code E66.01?
- Is there a weight history requirement (do I have to document a BMI for a certain period of time)
- All Centers of Excellence Programs will require a psychological evaluation. Ask if this will be covered.
- What is my deductible amount? Is this per calendar year or plan year? Is this an individual or family deductible?
- Once my deductible has been met, what percent of all eligible expenses are my responsibility up to my out of pocket maximum?
- What is my out of pocket maximum?
What happens if my insurance company does not cover bariatric surgery?
We do have self pay options for primary bariatric procedures. Please contact our care coordinators at 952-210-6325, option 1, for more information.
What else will I be required to do prior to surgery?
All patients will be required to undergo nutritional counseling with clearance as well psychological evaluation with clearance prior to surgery. Patients also will meet with our exercise physiologist. This is in no way intended to be a road block for the patient, but to ensure that each patient is ready physically, emotionally and psychologically for the changes following surgery.
Additionally, patients will need to lose some weight prior to surgery. Most patients do lose this just by changing their diet and following the dieticians recommendation however if a patient does struggle with this, Dr. Baker will work with that individual to develop a dietary plan with goals to help accomplish their weight loss. Patients will begin a protein diet prior to surgery to assist with weight loss. The reasoning is weight is lost initially internally which allows the liver to shrink and become more malleable. The liver sits on top of the stomach and must be retracted during weight loss surgery. With weight loss, manipulating the liver allows for an easier operation for the surgeon as well a safer operation for the patient.
Most patients following surgery are inpatient just one day following surgery. Leaving the Hospital, every patient is well prepared and is provided Dr. Baker's pager number at discharge for any questions or concerns. Although we allow each patient a three week period for post operative recovery, many patients chose to return to work much earlier than that. We do require a lifting restriction of no greater than 20 pounds for two to three weeks following surgery but there are no other physical restrictions other than that.
Additionally, patients will need to lose some weight prior to surgery. Most patients do lose this just by changing their diet and following the dieticians recommendation however if a patient does struggle with this, Dr. Baker will work with that individual to develop a dietary plan with goals to help accomplish their weight loss. Patients will begin a protein diet prior to surgery to assist with weight loss. The reasoning is weight is lost initially internally which allows the liver to shrink and become more malleable. The liver sits on top of the stomach and must be retracted during weight loss surgery. With weight loss, manipulating the liver allows for an easier operation for the surgeon as well a safer operation for the patient.
Most patients following surgery are inpatient just one day following surgery. Leaving the Hospital, every patient is well prepared and is provided Dr. Baker's pager number at discharge for any questions or concerns. Although we allow each patient a three week period for post operative recovery, many patients chose to return to work much earlier than that. We do require a lifting restriction of no greater than 20 pounds for two to three weeks following surgery but there are no other physical restrictions other than that.
What is the diet progression following surgery?
For the first few days following surgery, patients will be on a clear liquid diet only to allow for healing following surgery. Once home, patients typically start their protein drink and, if tolerated, a full liquid diet. It is recommended that patients drink a minimum of 64 ounces of water daily following bariatric surgery.
Week One thru Week Two:
Patients may begin with V8 juice, tomato juice or tomato soup diluted 1:1. Low fat, low calorie, strained cream soups, any flavor. (Example: Healthy Choice or Campbell's Select)
Week Three:
Patients may begin pureed foods in addition to the choices above.
Week Four and Five:
Patients progress to a soft food plan.
Week Six:
Patients will resume normal food.
Following surgery, patients must not drink with meals and must wait 30 minutes following a meal to drink again. All food must be chewed to applesauce consistency (chewing 25 - 30 times). Patients should also be exercising 30 minutes daily.
Week One thru Week Two:
Patients may begin with V8 juice, tomato juice or tomato soup diluted 1:1. Low fat, low calorie, strained cream soups, any flavor. (Example: Healthy Choice or Campbell's Select)
Week Three:
Patients may begin pureed foods in addition to the choices above.
Week Four and Five:
Patients progress to a soft food plan.
Week Six:
Patients will resume normal food.
Following surgery, patients must not drink with meals and must wait 30 minutes following a meal to drink again. All food must be chewed to applesauce consistency (chewing 25 - 30 times). Patients should also be exercising 30 minutes daily.
Two Twelve Medical Center, 111 Hundermark Road, Suite 115 N, Chaska, MN 55318 Phone: 952-210-6325, option 1